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The Nature of Anorexia

By Judith Warner June 15, 2006 10:30 pmJune 15, 2006 10:30 pm

Recently, I was mooning around in the parenting section of our local bookstore, licking my wounds after a particularly unpleasant Mommy run-in, and vaguely re-reading Rosalind Wiseman’s “Queen Bees and Wannabes.” I was wondering if there was anything original to say about grown-up mean girls and good female friendship, when another local mom, seeing me reach for Wiseman’s book, stepped up to recommend I read “Stressed-Out Girls,” by Roni Cohen-Sandler.

It’s a must-read, she said; it was a topic she herself had thought about a great deal, particularly this past year, as her daughter and her friends applied to college. It was a topic she worried about, she said, because her daughter is anorexic.

This led to a mini-conversation about anorexia, a subject that has been on my mind often lately, as I’ve listened to the third-grade girls I know talk endlessly about fat and “fitness” and skinniness and modeling. When I shared this observation the woman mentioned the names of some local specialists who might come speak at our school, and then talked about work being done at the University of Pennsylvania to prove that anorexia is in large measure genetic.

“Well, when my daughter got sick,” she said, her face suddenly becoming hard, “the school nurse said: ‘Normally, I blame the parents, but in your daughter’s case, I just can’t.’ ”

That’s not what I meant to say, I opened my mouth to protest, but just as the words were set to escape my lips, the other woman’s phone rang, and she began another conversation.

And I was left with the feeling — all too frequent these days — of having put my foot squarely in my mouth.

How many nights have I paced around the house writing imaginary columns, all variations on the theme of “That’s not what I meant to say”? As in: I never meant to say that attention deficit disorder is not a real condition. Nor that psychotropic medication doesn’t work. Nor that parents shouldn’t ever medicate their kids. Nor that parents should be blamed for their daughters’ eating disorders.

The motivation behind the genetic research, which has found that there is, at least in part, a biological component to anorexia nervosa and that certain people are genetically susceptible, could not be more noble. Full-blown anorexia (as opposed to the subclinical variety that abounds all around us) is relatively rare, but it has the highest mortality rate of any psychiatric illness. It also has a pretty poor cure rate, and the traditional mode of treatment available for it — psychotherapy focusing on family dynamics and behavior around food, aided sometimes by medication — is slow and onerous and, in the short term at least, only moderately effective: not really what you’d ideally want for a girl flirting with death.

“It’s still five or six years before people start getting better — and that’s with treatment,” Dr. Cynthia Bulik, a professor of eating disorders in the department of psychiatry at the University of North Carolina and a lead author of the U.N.C./Karolinska study, told the American Psychological Association’s monthly Monitor on Psychology. “If a doctor told me it was going to take me five years to get better from some illness, I’d have a hard time accepting that.”

The ultimate goal of genetic research is that it could lead to some kind of gene replacement therapy — but that’s far off in the future. The immediate goal is more practical: to find the genetic markers that predispose a person to develop anorexia nervosa, and thus better help families, doctors and schools intervene very early on, to keep kids — some boys now, too — from developing a full-fledged illness.

There are warning signs that a child may possess the inborn potential to make dieting a deadly obsession: personality traits like perfectionism, anxiety and drivenness. (Did we really need genetic research to tell us this? Apparently so, Dr. Bulik told me in a recent interview, because without the biological “proof,” people still tend to blame the victim for her “choices.”) Being aware of the dangers that can result when troublesome personality traits interact with today’s weight-obsessed Girl World can help parents try to prevent eating disorders before they take root and take on a life of their own.

I think all of this is great, important, pertinent and laudatory work. Some of the doctors affiliated with the N.I.M.H.-funded research project have posted an online guide to helping prevent eating disorders, which I think should be required reading for every parent and educator.

But here’s where I begin to have a problem: There is a major disconnect between how the genetics researchers talk about anorexia nervosa and how the popular media and parents talk about it. One striking example: Newsweek, which last December ran a cover story, eye-catchingly subtitled, “No One To Blame,” the point of which was to convince parents that as far as anorexia goes, they are basically irrelevant.

The Newsweek story did not transmit to parents the important insights of the genetics researchers: namely that parents need to get on the stick and do what they can to prevent illness in their genetically susceptible children. Instead, it gave parents a bit of a “pep talk” — to borrow a term from one “family-friendly” doctor quoted in the story — by asserting, “Parents do play a role, but most often it’s a genetic one.”

This goes counter to the message that Dr. Bulik, the eating disorder specialist, drove home to me this spring when I interviewed her about the U.N.C. study. “Genetics load the gun, but environment pulls the trigger,” she stated.

What I took away from that interview was this: Parents can’t let themselves entirely off the hook. Not (I repeat: not) because they are directly responsible for “causing” anorexia nervosa — a complex illness that has many complex causes — but because they can play an important role in encouraging or discouraging the disorder’s development.

Parents have a huge role to play in mediating the cultural influences that give anorexia its particular form of expression. Parents must be gatekeepers, arbiters, interpreters, relativizers of all the awful messages about body size and self-worth and the possibility of perfection that girls (and boys) are flooded with each day. They need to try to teach their children to respect their bodies, to value themselves as individuals and to reject unhealthy dieting — as well as unhealthy attitudes about performance, sexuality and success.

Parents can’t remake the personality types that their children are born with. They can’t undo a genetic legacy of anxiety or depression or perfectionism. They can’t entirely sanitize the cultural environment in which their children are raised. But they can try — tentatively, imperfectly, sometimes fruitlessly, perhaps — not to pull any triggers.

On another note: I would like to clear up something that I feel, due to my own lack of clarity, did not come across properly to readers last week. My prime emotion regarding the moms who bake, organize and generally run things for the rest of us, is not disdain.

Thank you for this column–it’s always good to reinforce the idea that although a disease like anorexia (or depression or ADD or…) is not anyone’s fault, that doesn’t mean we’re powerless against it.

Popular media has a long history of distorting scientific research, especially when it comes to the issue of genetics and behavior. Whether we’re dealing with anorexia or obesity or the sexual behavior of drosophila, the misunderstanding of how genes interact with environment is everywhere. I like to think of it this way: you could have a genetic trait that caused you to turn orange whenever the temperature hit zero. If you lived in Chicago this would happen all winter, but if you lived in Hawaii, then you would never exhibit the trait and thus never know about it.

Any biology professor worth her salt will tell you that the ‘nature versus nurture’ debate is moot. When it comes to the question, ‘Is it genes or environment?’ the answer is ‘Yes’.

The true value of finding genetic links may not be their direct role in developing new therapies but in legitimizing the biological basis of anorexia. Anorexia is one of the best examples of the synergistic interplay between genetics and culture in mental health. Like other those suffering from other mental health conditions, anorexics are often treated with more disdain than pity. Genetic markers may help to convince grantmakers, scientists, and the public that anorexia is a legitimate disease requiring good treatments. This is especially important as JAMA showed this week that Prozac isn’t as effective for anorexia as it is for bulimia.

I also follow the “middle way” you hew. You don’t side completely with genetics or environment in an analysis of anorexia’s cause. You found a view of ADD that lay between the disease model and ADD/HD as a social syndrome linked to overstimulation and anxiety.

The closest analogy to anorexia is alcoholism, which can manifest years after kids leave a teetoalling home environment. Parents can in advance educate kids about their risks, warning signs etc. Same thing with anorexia. Both are very tough to cure. We have a few of these risk factors in the family and my heart goes out to other parents dealing with these intractable problems.

Thanks for an important message to parents: you do make a difference. Two years ago my then 14 year old daughter flirted with anorexia and was down to 99 lbs at 5’3″. She has a perfectionist streak, among other genetically inherited issues like ADD, and this was her way of coping with the social throes of middle school. Luckily, early intervention and therapy have her at a much healthier 110 lbs today.

As someone who went through years of starvation for the sake of being thin, I’ve taken a lot of time over the past few years to really look at what affected my decisions about eating (or the lack of it). From my experience, I would say that Dr. Bulik says. There were a number of environmental factors that I have noticed in hindsight, though I know that it is part of me, as well. It’s been 7 years since I’ve done a starve, but the inclination is there waiting (again) for the outside influences to bring it out once more. I don’t blame my mother, I am ultimately the person who didn’t eat, but I can see the small things that she said and did unknowingly that affected me. As a mother of a young girl, I am always cognizant of my role in her development and I pray that I can avoid those mis-steps that my mother took. I’m quite sure I will, at the same time, be making my own in other ways. It’s the nature of parenting.

Your point is true for all kinds of problems kids face today–alcoholism, drug use, early sexual activity, depression, social anxiety, etc. Parents–regardless of the childs genetic make up–need to actively work to make their children love and respect themselves, warts and all. The best way to do that is also the hardest–learn to love yourself, warts and all and be willing to show those warts to your children. All too often, our society looks for reasons and explanations for things instead of dealing with them. Finding out the reasons can be helpful, but it does not eliminate the need to deal with the issues.

Those articles make me very nervous too. Did you read the one about the right diet leading to less aggresive behavior? Or a gene that makes you fat, daring, etc? Almost like we had no chance of ever guiding our own life, like if all was predisposed.

I think we all have one tendency or another to battle all our lives, and that’s what good judgment, temperance and will power are for. These values are difficult to teach, and learn, but are THE base to a truly meaningful and full life.

Thanks for a very thought provoking article. I have been very conscious of the anorexia issue as I struggled through the toddler and preschool mealtime battles with my daughter. As we look forward to kindergarten and elementary school I am more than ever concerned that she develop a healthy attitude towards food and her body. Your identifying prefectionism as an factor has reinforced this. Though I think that many the major environmental stresses that push towards eating disorders are outside the family I am going to take a long hard look at my attitude towards the 10-15 lbs that I would rather not have and how that battle might affect my daughter.

I’m somewhat skeptical of the genetic argument – is it possible that someone who suffered from an eating disorder would unknowingly pass on their behaviors to their children through socialization? Or perhaps some people with eating disorders see the behavior in a sibling and mimic it? I know two sets of sisters who have battled with eating disorders, and though their behavior may be linked to common genes, I wonder if their attitudes and behavior may be reinforced by their constant proximity to one another.

Although I am happy to see you ackowledge anorexia as a disease and not just a lifestyle choice. As a former anorexic, I only recently found out that my mother had been anorexic at the exact same as me, and that my brother had been bulimic. So, to state that the genetic component to anorexia is non-important seems wrong-headed to me.

I’m intrigued by Rich’s comment that “we don’t want to believe” that intelligence is genetic. Maybe I don’t get out much, but pretty much everyone I know believes that there is a strong genetic component to intelligence. Is there someplace (the Upper West Side of Manhattan?) where the implications of this belief are politically inconvenient? School achievement depends on many factors, intelligence being one, while “environment” and “culture” are also big. There are also therapies that can “rewire” the brain of someone who is developmentally damaged that can raise IQ scores, but the genetic component is still highly influential.

As the mother of two small girls and stepmother of a freshman in college, this article was particularly important to me. We live in an incredibly competitive area where the teenagers start hitting the gym early and mothers are permanent fixtures in the health clubs. We do not know if there is a genetic disposition in our family for eating disorders but the environmental pressures are great. As a result, we have made a conscious choice to talk about exercise and good eating habits only in the context that these will make you strong and healthy. The words “fat”, “diet”, “overweight” are studiously avoided in our household. I can not control the media or the influences they will encounter in our area, but I can attempt to provide them with some perspective in our home. I hope it is enough.

I was going to make a joke suggesting you take on autism, which would complete the trifecta of ADHD and anorexia of most-worrisome modern childhood diseases – at least under “A” – and REALLY give yourself a migraine! But it seemed more important to point out that you’re doing the hardest thing one can do socially – talking to other parents on the most sensitive issues concerning their children – and that you have escaped a general stoning thus far. What you’re doing is DIFFICULT. Foot-in-mouth disease is an inevitable side-effect of the effort. Take two Excedrin and continue writing, please!

As someone that suffered from multiple eating disorders, I can see the combination of nuture and nature. Depression addictions and obsessive disorders run on my mom\’s side of the family – manifesting them differently with different individuals. But I also can see the environmental triggers – Chubby kid being bribed to lose weight, chaotic home life, need for order, parental demands for perfectionism, blah blah. Not saying this to blame, just to observe.

But I also worry about societal expectations. My kids do not share my DNA- they are adopted. And already my daughter – who\’s six – is controlling about food. She can\’t eat if there\’s a big portion on her plate – it makes her tense. We never force her to clean her plate, but she just can\’t bring herself to start if it\’s too big. She\’ll ultimately eat her fill, but it\’s got to start w/a small portion. This is so much like anorexia we got really really scared. What we\’ve done is allow her to control what goes on her plate. And that seems to help. She\’ll take seconds or thirds if she\’s hungry. But I see the control factor and the tension when there\’s a lot in front of her – something I remember feeling from my worst days of anorexia and I am scared.

And this comes after being very conscious to do everything to make sure she feels valued for who she is, isn\’t body conscious and all of that, wanting to avoid any problems I had.

I just think it\’s how she is and I think she\’s always shown signs of needing to control her environment after the early disrpution of losing birth mom, then losing trusted caregiver in an orphanage before she came to us.

Perhaps a bit late to comment on this, but having suffered and recovered, from an eating disorder, it was with a degree of “relief” that I discovered that my grandmother abused laxatives for most of her life. My father has food issues…so perhaps if I had had a daughter, this knowledge would have at least made me more aware of the genetic element to eating disorders.
As Deborah says, a scary topic.